Laserfiche WebLink
SAN JOAQUIN Environm REGIRVED <br /> - - <br /> COUNTY -- <br /> MAR 0 5 2024 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIJNVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name Chevron # 372736 17 Phone # <br /> I Address 9484 West Lane Stockton A 95210 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Chevron Products Company Phone # 925 842 - 9002 <br /> C Contractor Name Wayne Perry Phone # 657 262 -8195 <br /> 0 <br /> N Contractor Address 8281 Commonwealth CA Lic # <br /> T 300345 Class <br /> ACP I C1 OR C61 D40ha7rS� <br /> A InsurerEverest National Inc Co . Work comp # CA10003737231 <br /> T ICC Technician ' s Name Jesse PUlldo Expiration Date 12/ 17/24 <br /> R ICC Installer' s Name Jesse Pulido Expiration Date 12/ 17/24 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc. ) Installed <br /> T 87 main 15K Petrolem <br /> A 91 12K Petrolem <br /> N <br /> K Diesel 12K Diesel <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions) <br /> A <br /> N ,/ � �- 1 , <br /> Plan Reviewers Name i ��� Date <br /> G <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER 'S COMPENSATION LAWS OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Permit Coordinator Date 3/ 1 /2024 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Becky Gallego TITLE Permit Coordinator PHONE # 657 262- 8195 <br /> ADDRESS 8281 Commonwealth Ave , Buena Park Ca 90621 <br /> SIGNATURE �ef DATE 3/ 1 /24 <br /> 2of6 <br />